Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald's to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.
He's still living on the streets.
"I'll be honest, I don't really sleep too much," says Ed, who's 51 and struggling with addiction. "Every four or five days I get a couple hours."
NPR agreed not to use his last name because he uses illegal drugs.
Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. But the coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. It still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.
When his usual shelter wasn't an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet, and if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn't want to place him in an inpatient facility until he'd gotten the pinkeye checked out. But he couldn't see a doctor because he didn't have a phone for a telehealth appointment.
"I got myself stuck, and I'm trying to pull everything back together before it totally blows up," he says.
People in Ed's situation are exactly who Rosalind Pichardo wants to help. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She'd head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.
She'd hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city's syringe exchange.
When Pennsylvania's stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets, nearby and able to revive them if they overdosed.
So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the nation's largest syringe exchange, says that during the first month of the city's stay-at-home order, they handed out almost twice as much Narcan as usual.
After the lockdowns and social isolation began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia's fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo thinks that's evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to each other.
But not always: Pichardo says users don't always have a buddy to keep watch, and first responders seem much more hesitant about intervening during the pandemic. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.
To reverse the overdoses, Pichardo crouched over the individuals, who she said had started turning blue as their oxygen levels dropped. She injected the nasal spray into their nose, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person's lungs and avoids mouth to mouth resuscitation. Between the three people, she says, it took six doses of Narcan to revive them.The police officers didn't step in to help, but did toss several of those doses at her as she worked.
"I don't expect 'em to give 'em rescue breaths if they don't want to, but at least administer the life-saving drug," Pichardo says. In her own work as a volunteer, she estimates she has reversed almost 400 overdoses. "There's social distancing — to a limit," Pichardo says, "I think when someone's life is in jeopardy, they're worth saving. You just can't watch people die."
Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low, and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists say the decreased law enforcement emboldened drug dealers in Kensington, where open air drug sales and use are common.
"You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product's got some good PPE gear," says Pichardo.
More dealers working openly on the street has led to more fights over territory, she adds , which in turn has meant more violence. While overall crime in Philadelphia and other major cities has gone down during the pandemic, gun violence has spiked. Police resumed arrests at the beginning of May.
Now, when she goes outside to walk the streets and hand out Narcan, Pichardo has added a few things to her bag of hand-out supplies: face masks, gloves, and gun locks.
"It's like the survival kit of the hood," she says.
For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal.
Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cell phones to those who are homeless or coming out of jail, so they can make a telehealth appointment to quickly get a prescription for those drugs. And during the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.
"If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place," says Ben Cocchiaro, a doctor who treats people with substance-use disorder.
Cocchiaro says the whole point of addiction treatment is to make help easy to get as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward, too.